If Covid-19 has shown us anything in these fast moving and uncertain times, it’s how resilient NHS staff are in the most strained and stressful situations. Patient demand has probably never been higher across the UK and yet the health service has also had to contend with the need to reduce the risk of coronavirus exposure to both staff and patients.
Providers have had little choice but to change the ways in which they normally operate – and one key change has been the increased use of online, telephone and video consultations. Many GP practices have stopped offering routine face-to-face appointments and moved to a triage model. Hospitals are also making greater use of telephone and video systems to consult with patients and manage ongoing care where appropriate to reduce unnecessary close contact.
The GMC welcomes innovations in medical practice that enable good care for patients and provides guidance to assist doctors in managing patient safety risks when treating patients remotely. Remote consulting allows patients access to new or ongoing medical advice while protecting other patients, staff and clinicians from possible exposure to the virus. But healthcare staff must be aware of the risks and take practical steps to mitigate these and avoid patient safety issues.
Each service will have their own particular approach to remote consultations but here we offer some general advice
New procedures and technologyNot all doctors will be accustomed to assessing patients over the phone or using remote technology. Appropriate time should be set aside for training/peer support and to put supervision in place. It should also be recognised that some patient consultations using remote technology will take more time and this should be factored in during the triage process.
Triage and call-back
Triage and call-back procedures need to be structured. Patients requesting or being offered a remote consultation should be given a clear timeframe when they can expect to be contacted and instructed to phone back if they are not contacted. This will act as a safety net for any technical issues or potential misunderstandings. Reception staff should ensure contact details are correct along with the reason for the call.Provide clear guidance on pursuing call-backs and how many attempts should be made before recording a failed contact – but ensure flexibility according to particular circumstances (e.g. vulnerable patients).
General practices should also take care to manage remote appointment allocation equitably to ensure that the most assertive patients are not prioritised at the expense of others who may have more serious problems.
Is a remote consultation appropriate?Remember that patient safety always comes first. You must be confident that assessment via remote means will be adequate. Establish quickly whether the patient may need further review or a face-to-face examination, and direct them to the most appropriate service. Keep up to date with local health service procedures in order to be able to advise and signpost your patients.
Ensuring patient confidentialityRemote consultations may be held with a patient or someone making contact on behalf of that patient. A priority is therefore to establish beyond doubt the identity of the patient and/or their representative. This may involve going further than simply asking for a name and date of birth. Consider patient specific questions such as: “can you tell me when your last appointment was and who it was with”. If you are dealing with someone purporting to be a patient’s representative, ensure that you have a record of the patient’s consent to discuss matters with that person and/or appropriate documentation of any welfare power of attorney.
Take adequate measures to maintain confidentiality. Ensure there is no risk of being overheard, especially if you are working outside usual clinical surroundings. Consider also whether the patient is in a private setting and address this before discussing personal health matters.
Ensure understandingEnsure that the patient understands why a remote consultation is necessary and that arrangements can be made for a face-to-face assessment if indicated. Allow sufficient time in remote consultations to listen carefully to the information provided and to make certain that the individual you are consulting with is clear on what you are advising.
Para-verbal communicationBe aware of the increased importance of “para-verbal communication”, i.e. tone and nuance of voice and body language (in video consultations). Being unable to see or examine a patient is an obvious disadvantage and may require additional time for an individual to “open up” about the presenting complaint. Again, consider arranging for a face-to-ask examination if there is any doubt.
Remote prescribingPrescribing can be particularly difficult in remote consultations. Checking the patient’s understanding of dosage, contraindications and other issues will be more problematic. Telephone consultations can take just as long as face-to-face appointments (particularly for patients who may have more complex or multiple conditions) and allowing adequate time is important to ensure safe compliance. The GMC has stated that it supports the use of remote prescribing that follows its prescribing guidance used in consultation with a patient in person or online.
The GMC also recently conducted a consultation seeking views on revised guidance on prescribing and managing medicines and devices. The final guidance document is due to be published in early 2021.
Good record keeping following a remote consultation is essential. Record clearly the reason why a remote consultation was used and document the mode of communication (e.g. telephone or video). Make an adequate note of information provided to the patient or carer, including specifics on medications prescribed and safety netting advice (red flags relevant to that patient). Record referrals or signposting to another service or clinician.
Justify clinical decisions including (where appropriate) the decision not to undertake a face-to-face assessment. New patients can present particular challenges if their medical records are not accessible. Should you feel unable to safely assess/manage a patient, you should advise a face-to-face examination or another alternative and record that advice.
Remote consulting outside the UK
Patients may sometimes make contact from outside the UK, especially with restricted travel in place. Remember that your indemnity may only cover patient consultations undertaken in the UK (check with your medical defence organisation). Encourage patients in these circumstances to seek advice and assistance from local medical services who can offer face-to-face assessment and treatment options. The GMC provides general advice to doctors about offering remote services to patients overseas.
Vulnerable or at-risk patients
A specific concern that has arisen during the pandemic is the protection of vulnerable or at-risk patients during remote consulting. Some patients may be disadvantaged, for example those who are technically inept, hard of hearing, or living in an unstable domestic environment. Seek confirmation that important advice has been understood and consider carefully the need for face-to-face assessment.
Patients experiencing domestic abuse or violence may no longer have the sanctuary of a private face-to-face consultation with their doctor, and telephone or video calls could be overheard or even recorded by a perpetrator. Consider asking directly if a patient is free to talk about confidential matters and if there is somewhere more private. Observe and gauge patient reactions and be vigilant to unusual behaviours, such as looking for permission from someone before speaking or wearing inappropriate clothing indoors that covers exposed body parts. Use your instincts and consider offering a face-to-face appointment.
Concluding a remote consolation
Be sure to restate the agreed position and any required actions to the patient when concluding a remote consultation. This may be your last chance to ask for clarification and pick up something important (in case you have been “barking up the wrong tree”). The patient will also be more reassured.
Work within your local hospital or practice policies but base your decisions on recognised guidelines and sound clinical judgement. Should you conclude that a face-to-face appointment is required for a particular patient but is not possible, report your concerns to your manager or a senior clinician as per GMC guidance. You can also contact MDDUS for advice.
Departing from established procedures
The GMC published guidance at the outset of the pandemic on adapting practice to cope with patient demand during the coronavirus outbreak. They understand that special measures may needed to protect your patients and yourself. The GMC states:
“It is likely that as the situation develops, some doctors will need to depart from established procedures to care for patients.”
The GMC has also advised patients to prepare for possible changes in normal practice:
“Doctors, and the whole healthcare team, may be under considerable pressure at the moment. The impact of coronavirus means they might need to deliver care in different ways.”
Ongoing communication with patients can reduce uncertainty or resistance to these temporary measures. Significant service announcements should be shared promptly through organisational social media channels or via text messaging services.
Summary points in remote consultations
- Maintain privacy in your own workspace at all times. Confirm patient identity or (if appropriate) consent to speak with someone who is not the patient.
- Take time to establish patient needs and ensure understanding of the advice you are providing.
- Keep adequate records of all information given to the patient, including medication prescribed and safety netting advice.
- Consult GMC guidance on Good Medical Practice but recognise the need to adapt practice in some circumstances and seek advice.